Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment
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RESEARCH
Impact of advance directives on the variability between intensivists in the decisions to forgo life‑sustaining treatment Margot Smirdec1, Mercé Jourdain2, Virginie Guastella3, Céline Lambert4, Jean‑Christophe Richard5, Laurent Argaud6, Samir Jaber7, Kada Klouche8, Anne Medard9, Jean Reignier10, Jean‑Philippe Rigaud11, Jean‑Marc Doise12, Russell Chabanne13, Bertrand Souweine14, Jeremy Bourenne15, Julie Delmas16, Pierre‑Marie Bertrand17, Philippe Verdier18, Jean‑Pierre Quenot19, Cecile Aubron20, Nathanael Eisenmann21, Pierre Asfar22, Alexandre Fratani23, Jean Dellamonica24, Nicolas Terzi25, Jean‑Michel Constantin26, Axelle Van Lander27,28, Renaud Guerin29, Bruno Pereira4 and Alexandre Lautrette21,30,31*
Abstract Background: There is wide variability between intensivists in the decisions to forgo life-sustaining treatment (DFLST). Advance directives (ADs) allow patients to communicate their end-of-life wishes to physicians. We assessed whether ADs reduced variability in DFLSTs between intensivists. Methods: We conducted a multicenter, prospective, simulation study. Eight patients expressed their wishes in ADs after being informed about DFLSTs by an intensivist-investigator. The participating intensivists answered ten ques‑ tions about the DFLSTs of each patient in two scenarios, referring to patients’ characteristics without ADs (round 1) and then with (round 2). DFLST score ranged from 0 (no-DFLST) to 10 (DFLST for all questions). The main outcome was variability in DFLSTs between intensivists, expressed as relative standard deviation (RSD). Results: A total of 19,680 decisions made by 123 intensivists from 27 ICUs were analyzed. The DFLST score was higher with ADs than without (6.02 95% CI [5.85; 6.19] vs 4.92 95% CI [4.75; 5.10], p
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